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PUBLIC H SERVICES-ENVIRONMENTAL Hx. H DIVISION <br /> SITE NAME ' n ADDRESS / f cITGa�/l <br /> a <br /> OWNER NAMESd ' low= PHONE # <br /> CONTRACTOR %/j / I CONT. PHONE # <br /> FIRE PERMIT <br /> R_.F'*20VAL CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR,`, DATE 6 f J' TANK39 ,g,�y <br /> -- i <br /> R RINSEDY N) METHOD RINSE AMQUNT <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> E IMMIFEST OR OTHER Y <br /> V VAPORS PURGED N) (METHOD 1 AMOUNT USED <br /> A <br /> P READING AT REMOVAL I L.E.L. : L 02 : <br /> O ` <br /> R COMMENTS <br /> r <br /> C TANK MATERIAL (STEM, FIBERGLAh, OTHr ) <br /> O <br /> N TANK CONDITION conn POO HOLES) ` <br /> S <br /> T PIPE MATERTAL ST2 , IBERGLAS OTHER) 'Jig FEET <br /> PIPE CONDITION (GOOD, oQR HOLES) <br /> DEPTH SOIL TYPEOBSERVATION ( SAMPLE <br /> A <br /> N i <br /> K <br /> S EXCAVATION SIZE X X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPEOBSERVATION SAMPLE , <br /> P P <br /> L I I I I <br /> I P I <br /> N I I I <br /> G I <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 HOURS SINCE DEWATERING: <br /> a <br /> of. SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLO SURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />